Practice Diagnosis in General Practice

Excluding serious illness in feverish children in primary care: restricted rule-out method for diagnosis

BMJ 2009; 338 doi: (Published 20 April 2009) Cite this as: BMJ 2009;338:b1187
  1. Matthew J Thompson, senior clinical scientist and general practitioner1,
  2. Anthony Harnden, university lecturer1,
  3. Chris Del Mar, dean2
  1. 1Department of Primary Health Care, University of Oxford, England
  2. 2Faculty of Health Sciences and Medicine, Bond University, Australia
  1. Correspondence to: M J Thompson matthew.thompson{at}

    Two children presenting to general practice with fever show how general practitioners use restricted rule-out, one of the strategies to make a diagnosis set out by Heneghan and colleagues (doi:10.1136/bmj.b946)

    Case scenarios

    Consider two common scenarios in primary care.

    Child 1: A mother calls the out of hours service in the early evening about her 3 year old son. He was seen earlier in the week with cough and runny nose, and the general practitioner (GP) diagnosed an upper respiratory tract infection. He has been getting more miserable and irritable, is lying on the sofa reluctant to move, looks “washed out,” and has a fever. His mother is worried: “Could it be meningitis, doctor?”

    Child 2: A 2 year old girl is brought to your morning surgery with a history of a fever that started during the night. You have already seen several children this morning with a non-specific but seemingly mild viral illness.

    The diagnostic dilemma

    The list of possible diagnoses for febrile children seen in primary care is long. Identifying children who may have a serious illness can be difficult and is at the heart of decisions to prescribe, investigate, and refer to hospital. Serious infections (including pneumonia, meningitis, septicaemia, appendicitis) account for less than 1% of children presenting to primary care,1 2 yet they are leading causes of morbidity and mortality in children. One of the key challenges for primary care practitioners is trying to balance the risk of missing a serious disease against unnecessary investigation or referral. The diagnostic process hinges on the need to rule out (exclude) serious illnesses.

    The diagnostic approach: the restricted rule-out

    Many doctors come to use some variant of the restricted rule-out method, which recognises that we cannot rule out all of the alternative diagnoses for each presenting complaint, but that there is a short list of serious ones …

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